CME Information:Sexuality Education in North American Medical Schools: Current Status and Future Directions (CME)

CME Information: Sexuality Education in North American Medical

Schools: Current Status and Future Directionsjsm_2932 3

Accreditation and Designation Statement Sexual Medicine is double-blinded. As such, the identities Blackwell Futura Media Services is accredited by of the reviewers are not disclosed in line with the stan- the Accreditation Council for Continuing Medical dard accepted practices of medical journal peer review. Education to provide continuing medical education for Conflicts of interest have been identified and physicians. resolved in accordance with Blackwell Futura Media Blackwell Futura Media Services designates this Services’ Policy on Activity Disclosure and Conflict of journal-based CME activity for a maximum of 1.0 AMA Interest. The primary resolution method used was peer PRA Category 1 Credit™. Physicians should only claim review and review by a non-conflicted expert. credit commensurate with the extent of their participation in the activity. Instructions on Receiving Credit This activity is intended for physicians. For information Educational Objectives on applicability and acceptance of continuing medical Upon completion of this educational activity, partici- education credit for this activity, please consult your pants will be better able to: professional licensing board. • Review the current state of the art in sexuality This activity is designed to be completed within one education for North American medical students and hour; physicians should claim only those credits that to articulate future directions for improvement. reflect the time actually spent in the activity. Tosuccess- fully earn credit, participants must complete the activity during the valid credit period, which is up to two years Activity Disclosures from initial publication. Additionally, up to 3 attempts No commercial support has been accepted related to and a score of 70% or better is needed to pass the post the development or publication of this activity. test. Alan W. Shindel, MD: Dr. Shindel has served on the Follow these steps to earn credit: speaker’s bureau for Endo. He has served as a consultant • Log on to www.wileyhealthlearning.com/issm for Group H, AMS, and Cerner. • Read the target audience, educational objectives, and Sharon J. Parish, MD: No relevant financial relation- activity disclosures. ships to disclose. • Read the activity contents in print or online format. • Reflect on the activity contents. This activity underwent peer review in line with the • Access the CME Exam, and choose the best answer to standards of editorial integrity and publication ethics each question. maintained by Journal of Sexual Medicine. The peer • Complete the required evaluation component of the reviewers disclose the following relevant financial rela- activity. tionships. The peer review process for Journal of • Claim your Certificate.

J Sex Med 2013;10:3–18 3 Continuing Medical Education

Sexuality Education in North American Medical Schools:

Current Status and Future Directionsjsm_2987 4..17

Alan W. Shindel, MD* and Sharon J. Parish, MD† *Department of Urology, University of California, Davis, Sacramento, CA, USA; †Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA

DOI: 10.1111/j.1743-6109.2012.02987.x

ABSTRACT

Introduction. Both the general public and individual patients expect healthcare providers to be knowledgeable and approachable regarding sexual health. Despite this expectation there are no universal standards or expectations regarding the sexuality education of medical students. Aims. To review the current state of the art in sexuality education for North American medical students and to articulate future directions for improvement. Methods. Evaluation of: (i) peer-reviewed literature on sexuality education (focusing on undergraduate medical students); and (ii) recommendations for sexuality education from national and international public health organizations. Main Outcome Measures. Current status and future innovations for sexual health education in North American medical schools. Results. Although the importance of sexuality to patients is recognized, there is wide variation in both the quantity and quality of education on this topic in North American medical schools. Many sexual health education programs in medical schools are focused on prevention of unwanted pregnancy and sexually transmitted infection. Educational material on sexual function and dysfunction, female sexuality, abortion, and sexual minority groups is generally scant or absent. A number of novel interventions, many student initiated, have been implemented at various medical schools to improve the student’s training in sexual health matters. Conclusions. There is a tremendous opportunity to mold the next generation of healthcare providers to view healthy sexuality as a relevant patient concern. A comprehensive and uniform curriculum on human sexuality at the medical school level may substantially enhance the capacity of tomorrow’s physicians to provide optimal care for their patients irrespective of gender, sexual orientation, and individual sexual mores/beliefs. Shindel AW and Parish SJ. Sexuality education in North American medical schools: Current status and future directions. J Sex Med 2013;10:3–18. Key Words. Medical Education; Sexuality Education; Medical Students; Medical School

Introduction sexual rights of all people be recognized and upheld.” [1] he Pan American Health Organization Sexuality is a lifelong human experience [2]. All T (PAHO) deﬁnes sexual health as “the experi- physicians, regardless of specialty focus and/or ence of the ongoing process of physical, psycho- patient demographics, should have some familiar- logical, and socio-cultural wellbeing related to ity with sexuality and sexual function [3]. The sexuality. It is not merely the absence of dysfunc- extent to which medical doctors may play a role in tion, disease, and/or inﬁrmity. For sexual health to the sexual health of their patients is exponentially be attained and maintained, it is necessary that the greater today than at any other time in history [4].

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The U.S. National Institute of Health (NIH) vague. Recommended topics include: behavioral issued a statement indicating that healthcare pro- subjects; communication skills, medical conse- fessionals should be provided with: (i) courses in quences of common societal problems, such as effective sexual history taking; (ii) courses in the abuse; diverse cultures and belief systems, and diagnosis and management of sexual dysfunction; gender biases [7,9]. The expectation that physi- and (iii) an understanding of the interdisciplinary cians be knowledgeable about contraception and approach to the evaluation and management of the prevention of sexually transmitted diseases is sexual dysfunction [5]. well-supported and has led to the incorporation of Physicians have a leading role in providing curricula to address these important issues at most unbiased, accurate information on sexual practice medical schools in North America [16]. and behavior [6]. Physicians should be expected to In this review we will highlight the state of the have a greater grasp of not just the physiological art in sexuality education in North American foundations of sexual functioning but also of the medical schools. Particular focus will be devoted broader sociocultural, moral, and psychological toward recent curricular innovations. We will also implications of sexual health [7–9]. Sexual health is speculate on future directions that should be taken of great importance to virtually every person but to enhance student’s educational experience. each individual’s expression and understanding of While the general principles are intended toward sexuality is unique. Consequently, the well-trained individuals training in North America, sexuality is physician must be able to relate to patients with a a global and universally human concern and there- wide spectrum of personal circumstances and con- fore many of our findings/suggestions may be cerns [7,9]. applicable to other nations and regions. A recent study of Americans older than 50 years reported that just 38% and 22% of men and Methods women, respectively, had discussed sex with their A PubMed search was conducted for publications healthcare provider [2]. Physicians have contrib- pertaining to medical student education on sexu- uted to this by failing to “bridge the gap” in ality. References from particularly important addressing the needs of their patients for informa- sources were consulted for additional citations. We tion on sexuality [3]. McCance et al. reported that reviewed documents germane to sexual health that as few as 25% of primary care physicians surveyed have been produced by international bodies (such routinely asked patients about sexual well-being. as the World Health Organization, the United The majority of physicians who failed to inquire Nations, etc.) In this review, we speculate on the did so because they felt inadequately trained in implications and discuss ramifications of the given how to properly take a sexual history or evaluate a findings. Suggestions for future curricular innova- sexual problem [10]. In a survey of 1,154 practicing tions are summarized. obstetrician/gynecologists, Sobecki et al. reported that just 40% inquire about sexual problems and Results less than 30% inquire about sexual satisfaction. Over a quarter of respondents reported having Potential Barriers to Discussing Sexuality with expressed “disapproval” of their patient’s sexual Patients that May Be Addressed in Medical School practices [11]. Many physicians and students have difficulty facili- Sexuality education at the medical undergradu- tating conversations with their patients pertaining ate level is often inadequate to properly prepare to sex [3]. Potential reasons include fear of offend- future physicians for their future roles as sexual ing the patient, a notion that sexuality is not suf- health educators [9,12]. It has been reported that ficiently important, a personal discomfort with between 42% and 62% of contemporary medical sexuality, a lack of time related to concern for students find the training on sexuality issues that other pressing medical conditions, preconceptions they have received in medical school inadequate and value judgments about what constitutes [8,13–15]. The Liaison Committee on Medical “normal” and “healthy” sexual expression, con- Education (LCME, http://www.lcme.org) sets cur- cerns about the development of inappropriate feel- riculum requirements for undergraduate medical ings between patient and provider, differences in education; unfortunately, the current curricular age/language/culture, prejudices, prior traumatic requirements related to sexual health are rather experiences with sex, and a lack of knowledge on

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human sexuality and how to help patients with did not accept the offer to talk about sex; 1.2% sexual problems [3,6,12–14,17–23]. Both physi- responded negatively to a pre-visit questionnaire cians and students have greater difficulty broach- on sexuality, and just 2.5% reported that it was ing the topic of sexuality with patients of a difficult to talk about sex with their provider [27]. different gender [11,17,24] Even in clinical Data on female patient’s response to sexual health encounters where sexuality issues are addressed, inquiry are more ambiguous, with at least one providers may make patients uncomfortable by report indicating that some women believe provid- using medical jargon or vulgarity, inappropriate/ ers should only inquire about sexuality if it relates awkward/insensitive comments, making moral to an associated health problem [28] and other judgments on lifestyle choices, assuming things studies suggesting that women may welcome about the patient’s sexuality based on appearance inquiry on sexual health [3,29,30]. or other factors, or seeming to have an excessive or It is logical to speculate that considerate and prurient interest in the patient’s sexual life [25]. respectful inquiry into sexual life is unlikely to There is also evidence that a provider’s personal offend most patients of any gender, even in situa- experience of sex and sexuality may be associated tions where no presenting sexual concern is with difference in how they address the issue with present. It is important to note that although patients; a survey study of medical students in patients welcome the opportunity to discuss sexu- North America suggested that students at risk for ality, they prefer their physician to bring up the sexual dysfunction and those who had not engaged topic [31]. Informing the patient that sexual prob- in partnered sexual activity were more likely to lems are quite prevalent may help “normalize” the report discomfort addressing sexuality in the clini- experience of having a sexual dysfunction and cal context [15]. This finding is far from new [26]. enable patients to speak more freely and honestly Given this extensive list of potential barriers to [29]. Medical trainees should be informed and frank discussion of sex between patient and pro- encouraged to initiate conversations on sexuality vider, it is not surprising that both trainees and with their patients [29]. practicing physicians have trouble initiating conversations about sex with their patients. Many of The State of Undergraduate Sexual these barriers may be addressed during the educa- Health Education tional process and lessen provider’s difficulties In 1964 only three North American medical speaking with patients about sex. Indeed, percep- schools had formal curricula on sexuality [32]. tion of the adequacy of training in human sexuality During the 1960s and 1970s there was a dramatic during medical school was the strongest predictor expansion in the coverage of reproductive topics in of comfort in addressing sexuality clinically in the medical schools [32,33], although sexuality outside aforementioned survey of medical student sexual- of the reproductive context remained underrepre- ity [15]. sented with just 60% of medical schools including It does not appear that there is much basis for a sexuality curriculum and 32% offering electives the concern that provider inquiry about sexuality in human sexuality [34]. This heterogeneity per- and sexual function (assuming it is done with tact sisted through the 1970s, with a 1980 report indi- and sensitivity) will often lead to patient embar- cating that there was great variability between rassment. A survey of college and graduate stu- schools with respect to the sexuality curriculum dents indicated that healthcare-provider-initiated and that most of the material presented addressed conversations about sex were the most preferred issues of contraception and pregnancy [35]. means of acquiring sexual health knowledge. Sub- During this era less than half of medical schools jects were generally more satisfied with providers incorporated discussions of diagnosis and/or man- who were knowledgeable and comfortable dealing agement of sexual dysfunction [35]. with sexuality (75% and 68% of respondents, The most comprehensive recent information respectively) [8]. In a large study of men over age about the status of undergraduate sexual health 30, 70% responded favorably to questions about education in the United States and Canada is their sexual health. Five percent were neutral reported in a recent survey by Solursh et al. [36]. regarding discussing sexual issues, and about 10% In this survey, the person(s) responsible for the each expressed shyness or unwillingness to be overall undergraduate medical curriculum was questioned further regarding sexuality. Only 1.4% contacted at 141 medical schools; 101 valid

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responses (72%) were returned. Interestingly, Table 1 Required elements of medical school curricula follow-up outreach revealed that some of these in human sexuality (adapted from Parish and Clayton [7] nonrespondents failed to participate in the survey and Parish and Rubio-Aurioles [9]) secondary to complete absence of sexuality cur- Attitudes 1. Self-awareness and reflection on personal beliefs, values, ricula at their institution. The survey inquired and attitudes toward sex and how they may influence care of about the type of educational experiences, whether the patient they were mandatory or elective, whether they 2. Awareness of variability of “normal” sexual expression (gender identity, sexual orientation, etc.) were designed by single or multiple disciplines, 3. Awareness of ethical issues in sex, contraception, and and the number of course hours dedicated to relationships human sexuality. The questionnaire also assessed Knowledge specific content areas, as well as exposure to and 1. Knowledge of the biology of sexual development at the molecular and organismal level training in clinical settings addressing sexual prob- 2. Anatomy and physiology of human sexual response lems. Finally, the survey assessed the availability of 3. Reproductive biology (contraception, pregnancy, infertility) continuing medical education programs in sexual 4. Sexually transmitted infections 5. Psychological influences on sexual development medicine and related topics [36]. 6. Causes and correlates of sexual dysfunction (biological, A total of 84 respondents (83%) reported using psychological, social) a required lecture format for sexuality education. 7. Management options for sexual dysfunction 8. Impact of medical illnesses and their treatments on sexual Two thirds of the schools used a multidisciplinary function approach to teach sexual health, and three quarters 9. Sexuality in special populations (adolescent, aged, disabled) of the schools reported that psychiatry was the 10. Sociological issues (ethnicity, race, culture, religion, sexual orientation, and economic status) most frequently involved discipline. The majority 11. Lesbian/gay/bisexual/transgender sexuality and sexual health (54%) of the schools provided 3–10 hours of edu- care for these populations cation. The curricula of 96 respondents included 12. Sexual abuse and violence causes of sexual dysfunction (94%), treatment of Skills 1. Sexual history taking sexual dysfunction (85%), “variant” sexual identi- 2. Comfort with sexual language and terminology in a fashion fication (79%), and issues of sexuality in illness or understandable to patients disability (69%). While lecture-based learning on 3. Physical examination of the genitourinary/gynecological organs evaluation and treatment of sexual problems was 4. Integrated, multifactorial diagnosis of sexual dysfunction offered at most schools, only 42% offered clinical 5. Management of pharmacologically induced sexual training programs that focused on treating dysfunction patients with sexual problems and dysfunctions 6. Basics of behavior therapy for sexual dysfunction and 55% provided the students in clerkships with supervision in addressing patient’s sexuality issues. A variety of other topics and formats were lationships between various organs systems that reported by respondents [36]. pertain to sexual function; effective means of con- The Solursh et al. survey instrument was quite traception and safer sex; evaluation and treatment brief, and hence there is some ambiguity with of sexually transmitted infections (STIs); commu- respect to the findings of this study and the precise nication skills regarding sexuality between patient nature and manner in which the specified hours and providers as well as between providers; an are spent on sexuality education [36]. Regardless, it understanding of different means of sexual expres- is apparent from this report that medical students sion (with regard to sexual acts as well as sexual receive a broad range of non-standardized training orientation and preference); and the evaluation that varies from school to school. Important ele- and treatment of sexual dysfunctions such as erec- ments may not be adequately represented at many tile dysfunction, premature ejaculation, hypoactive schools [16]. sexual desire disorder, sexual arousal disorder, and anorgasmia, and sexual pain [37]. An in-depth Attitudes, Knowledge, and Skills description of recommended attitudes, knowledge, Sexual health curricula are typically divided into and skills for inclusion in medical school curricula attitude, knowledge, and skill components. We is presented in Table 1, modified from Parish and recommend that the knowledge component of a Clayton [7,9]. core sexual health curriculum for medical students Specialized issues, such as technical aspects of include genital anatomy and function; the interre- specialty procedures such as penile prosthesis

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placement or abortion, specific techniques of psy- Obedin-Maliver et al. in 2011 [44]. Deans of chosexual therapy, and issues most germane to medical curriculum at 176 North American osteo- specific patient populations may be more appro- pathic and allopathic medical schools completed a priate for students with a strong interest in sexual 13-item questionnaire on LGBT topics between health and a desire to make sexuality issues a focus March 2009 and March 2010. The median hours of their clinical practice [7,12]. For these students, of instruction in LGBT material in North Ameri- dedicated electives beyond the core curriculum can medical school was 5 hours (intraquartile may be of benefit. The exact scope of the elective range 3 to 8 hours), an apparent but slight could be tailored to a student’s interest and pref- improvement over the 1992 data. Approximately erence but should incorporate clinical interactions 75% of schools responded completely; of these with a diverse panel of patients; this may necessi- approximately 7% had no preclinical curriculum tate multidisciplinary training involving psychia- on LGBT issues and a third had no formal cur- try, urology, obstetrics/gynecology, internal riculum on LGBT issues during clinical years. medicine, family practice, and physical therapy. Canadian and osteopathic schools were more One example is the University of Massachusetts likely to not include LGBT curricular content, Medical School’s multidisciplinary fourth-year although this was not universal. Of 16 topics elective on women’s health, which encompasses deemed central to LGBT curricula, approximately several areas germane to women’s sexuality [19]. In 75% of respondent schools included at least half of some circumstances electives may lead to changes these when considering both required and elective in the core curriculum, as was evidenced at the coursework. Specific topics related to transgender medical schools of both Brown University and individuals (sex reassignment surgery, transition- Tufts University [38,39]. ing) and others relating to primary care issues which are prevalent in LGBT communities Special Issues in Sexual Health Education (domestic violence, substance abuse, chronic dis- Lesbian, Gay, Bisexual,Transgender (LGBT) Issues eases such as diabetes) were included by less than The American Medical Association (AMA) has half of respondent institutions. HIV and sexual released a policy statement acknowledging a dis- orientation were covered at more than 80% of proportionate burden of certain health problems respondent schools. Just 20% of schools included and a greater likelihood of hesitancy in discussing faculty development options for teaching LGBT health issues with providers among LGBT indi- content [44]. viduals [40]. The AMA has also advocated for A lack of training on LGBT health in medical LGBT awareness among physicians, starting with schools may be responsible for the findings of a education at the medical school level [41]. This 2006 report of sexual history taking in clinical interest culminated in a recent Institute of Medi- medical students, which indicated that less than cine report that highlighted important limitations half screened for same-sex sexual activity “always” and areas for future development in LGBT health or “often” when taking a sexual history and over [42]. These statements were made due to a his- 50% rarely or never determine a patient’s sexual torical lack of attention to the LGBT population orientation [45]. Students with a greater number at most medical schools. In 1992 survey of faculty of self-reported interactions with patients from at 126 U.S. medical schools, the average time LGBT communities were more likely to routinely allocated to LGBT topics was 3.5 hours. Eight of screen for same-sex sexual behaviors and sexual the 82 respondents (10%) reported that there was orientation; however, this may simply represent a no teaching on gay and lesbian issues during greater discovery rate of LGBT orientation by medical school training [43]. The student organi- students who already ask questions pertaining to zation Medical Students for Choice (MSC) this topic [45]. reported that LGBT topics are covered at just less Recent innovations for LGBT education have than half of medical schools during preclinical included elective offerings for preclinical students training; schools in the Southern United States on medical risks of LGBT communities, often as were significantly less likely to include these part of a more comprehensive sexuality elective topics [16]. opportunity [19,39,46]. A typical format includes A more contemporary study LGBT curricula in a 1-hour panel discussion of patients from LGBT North American medical schools was reported by communities with question and answer sessions

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followed by small group discussion and review of settings) gender-variant patients [46,49,53]. cases led by a faculty member, often from an However, the sexual health needs of individuals LGBT community [46]. Topics include LGBT with conservative and/or traditional notions of terms, homophobia, specific healthcare needs, sexual propriety may in some cases need to be and recognition that there is tremendous variabil- addressed by a provider with liberal or less- ity in the LGBT communities. Such electives restrictive notions of what is appropriate sexually. have been shown to lead to significant improve- Hence, it is important that all providers under- ments in students’ knowledge about healthcare stand their own beliefs on sexuality and recognize access issues in LGBT patients, enhanced aware- how that may influence their perceptions and care ness of the relevance of knowing the patient’s of patients [54]. sexual identity and practices to the provision of Students and providers have reported that they optimal health care, and increased willingness to often feel particular discomfort discussing sexual treat LGBT patients in practice [46]. Education behaviors such as masturbation, noncoital (i.e., on care of persons from LGBT communities can oral or anal) intercourse, same-gender sexuality/ also be integrated into general curricular com- encounters, extramarital affairs, consensual non- ponents (i.e., an LGBT patient who presents for monogamy, fetishism, and consensual sadoma- a health concern not related to their sexuality, sochistic activities [11,19,37]. Students may have etc.). little or no knowledge of such practices, or may Sexuality in the Young and Aged have moral objections to such behaviors [11]. While the personal beliefs of the student should be Students and practicing physicians have expressed respected, students should be educated on means significant discomfort in addressing sexuality in to recognize their own beliefs as their own opin- children/adolescents and in older patients [17,47]. ions rather than universal truths and avoid letting Children and adolescents need education on sexual them influence the care that is provided to patients development, puberty, boundaries, and decision [23]. Rather, students should focus on fair and making regarding sexual activity and contracep- unbiased education of their patients on potential tion [19]. Older patients are more likely to report health risks of their preferred sexual activities. In sexual dysfunctions and may be less likely to be extreme cases the student should learn that in cases familiar with and/or use barrier methods for pre- where disagreement is profound, referral to vention of STI, placing them at greater risk of another provider may be the most appropriate disease transmission [48,49]. While the sexual con- means of caring for the patient. cerns of the very young and the very old may tend to differ somewhat from those of the young and HIV and STI middle-aged adult population [48,50,51], sexuality The tremendous public health ramifications of is a topic germane to people of all ages and merits HIV infection in particular and STIs in general consideration by any provider who interacts with mandate that this topic be given substantial cover- patients [8]. Several case-based teaching initiatives age in the core curriculum of medical trainees. have incorporated standardized patient (SP) at the While the pathophysiology of HIV/STI is gener- extremes of age to enhance student comfort ally covered well in medical training [16,22], addressing the sexual health needs of these popu- potential areas for improvement in education lations [49,52]. Didactic lectures on these topics include training in psychosocial and counseling have also been implemented at some institutions as issues pertaining to testing and counseling part of the core curriculum [37]. [19,39,49]. These are of critical importance due to Specific Sexual Behaviors social behaviors surrounding HIV infection and Physicians must be equipped to relate empathi- other venereal diseases. Giving students the cally to individuals who may have sexual identities opportunity to hone skills in sexual health history and mores different from their own. Historically taking has been shown to enhance their facility at this has meant educating students with conserva- counseling patients on HIV/STI risk [52,55]. tive beliefs on about addressing sexuality in non- heterosexual patients, patients who engaged in Contraception extramarital, high-risk, or variant sexual behavior, A survey conducted through chapters of MSC at and (in some particularly progressive educational 77 medical schools (63% of the 122 invited to

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participate) indicated that pregnancy and contra- clinical rotations with abortion service providers ception are covered at virtually every medical generally find the experience valuable [57]. school during preclinical training (100% and 96%, Although coverage for the topic of abortion is respectively) [16]. While attention to contracep- variable, a survey of 100 third-year students com- tion in and of itself is a need that is being met, pleting their obstetrics/gynecology clerkship indi- questions remain on whether or not students cated that the vast majority (96%) thought receive knowledge on the full gamut of modern abortion was an important topic for coverage in contraceptive options. Oral contraceptive pills medical school [57]. Medical school electives on (OCPs) are the most routinely covered topic on abortion topics for preclinical students have been pregnancy prevention; other methods tended to advanced at some schools [39]. Oftentimes, an receive less or even no consideration, which is elective may be coupled with an opportunity to concerning given the relatively high failure rate of shadow in a clinical setting where abortion services OCPs and the advisability of nonhormonal or less are provided [39]; students with moral objections user-dependent forms of contraception for some to abortion are exempted from this activity. individuals [16]. Efforts should be made to ensure that students are aware of the various contraceptive Legal Aspects of Sexuality options available, including abstinence. It is also A particularly important medicolegal decision sur- critical that students be familiar with the failure rounds disclosure of a patient’s HIV/STI status to rates and potential complications of each option. the patient’s sexual partners [49]. A different set of rules may also apply to these test results in minors. Abortion A recent study indicated that these topics are of Abortion deserves special consideration secondary great interest to medical students and many desire to its highly controversial nature. Abortion is a more detailed coverage; at the same time, educa- very common procedure with significant public tors and facilitators often report a lack of knowl- health ramifications and physicians should have edge on this important topic [49]. Certain sexual some knowledge on this topic [8]. Elective abor- acts that are commonly practiced (such as oral sex) tion is covered during preclinical training at continue to be illegal in many American states. roughly two thirds of medical schools and preg- The frequency with which these laws are enforced nancy options counseling in 36% according to the may vary but providers should be familiar with MSC survey. The most frequently covered topic in local statues for common sexual behaviors such as the core curriculum is medical abortion [16], a oral sex, anal sex, extra- or premarital sex, and topic most often conveyed in lecture format [56]. nonsexual erotic activities such as bondage/ Schools in the southern United States were sig- domination sadomasochism. Attention could also nificantly less likely to include these topics [16]. be directed toward managing issues in adolescent This may not be an entirely accurate representa- sexuality where one partner is a legal adult (18 or tion of the overall medical school presence of 19) and the other an underage (<18 years) minor abortion topics since many schools did not [49]. respond and schools without MSC chapters may be less likely to have abortion teaching in the cur- Sexual Violence and Rape riculum [16]. Issues of sexual violence and rape are sensitive A survey of clinical clerkship directors for topics that evoke strong emotional reactions in obstetrics/gynecology rotations (78 respondents of most individuals and may be a source of substantial 126 invited, 62% response rate) indicated that no discomfort for healthcare providers [19]. Medical formal abortion education is provided to preclini- students must gain skills in relating to patients who cal students, third-year students on clinical rota- have been the victims of sexual violence so as to tions, and students of any level at 44%, 23%, and help them remove themselves from the situation 17% of medical schools, respectively. About one (in cases of ongoing abuse) and/or recover from third of third-year rotations offered a lecture on physical and emotional trauma. Small group dis- the topic of abortion; and 45% had an optional cussions and role play have been utilized to help clinical experience available for third- or fourth- students build up skills for helping these patients year students, although participation was generally [38,49]. Formal didactics may also play a role in low [56]. Students who do participate in optional providing context and general principles for

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proper management of this important public accomplished remains a topic for further research, health issue [19,37]. debate, and consideration. General Principles of Sexuality Education Lecture Format General Principles of Curriculum Development The large-scale didactic format for sexuality edu- There are many alternatives for imparting sexual- cation is the dominant paradigm in medical ity education to learners. Based on a review of school [36]. Despite some criticisms and limita- educational programs for practicing physicians, tions [58], it plays an important role in education Davis et al. reported that educational interven- due to its efficiency at conveying a standardized tions that promote interaction between partici- body of information to a large group [19,62]. pants (case discussion, role-play, or hands-on Core topics in anatomy and physiology are prob- practice sessions), have a mixed format of educa- ably best suited to this format. Supplementation tional styles, and follow an orderly sequence of with small groups and laboratories as appropriate topics are most effective at changing practice pat- is indubitably beneficial. Additional topics that terns and, potentially, healthcare outcomes. There may be considered for lecture-style teaching was less evidence to support a role of pure didactic include survey courses to introduce the scope of lectures at changing physician behavior [58]. the problem of sexual issues, the basic science These findings are in line with general principles physiology underlying these issues, and general of adult education which support learner-centered, principles of effective patient interaction [8,49]. active rather than passive interventions with focus- This format does not easily permit student- ing of topics relevant to the learner’s needs directed learning; other learning formats are [58–61]. useful as adjuncts to permit personalized goal In addition to particular teaching styles, consid- setting and self-assessment. eration should be given to cross-disciplinary col- Panel Discussions laboration as a key requirement for sexual health Panels permit experts of differing backgrounds to curriculum development in medical school [62]. express their opinions on topics of interest. This Harold Lief, the famed sexuality education format allows experts from various medical special- pioneer, acknowledged this over 40 years ago [32]. ties (urology, psychiatry, gynecology, sexology, Interdisciplinary collaboration is important physical therapy, primary care, etc.) to relate to because sexuality has ramifications that cross spe- students how they approach sexual problems in cialty boundaries and even beyond health care. On patients. Panels may also consist of professionals a more practical level greater university/faculty from various nonmedical backgrounds such as involvement will increase the incentive for cur- clergy, lawyers, public health experts, or individuals riculum directors to incorporate sexuality topics representing a diversity of sexual lifestyles/ into the already heavy medical student educational preferences (heterosexuals, LGBT people, non- program. Unfortunately, most contemporary monogamists, etc.) This intervention may help reports indicate that sexuality education at the students learn to relate to alternative points of view medical school level is often the province of a and has been highly rated when utilized for sexual- single or few educators, often from a single disci- ity education in resident physicians [12]. Ideally this pline such as psychiatry [37,63]. Diversity in the form of teaching incorporates a question and sexuality education faculty can only serve to enrich answer format. Toensure that important topics are the educational experience for students and there- covered adequately, panelists may articulate some fore should be considered an important goal for basic principles early in the session. curriculum development [19]. Sexual health curricula must be subject to robust Discussion Groups and rigorous evaluation. Development of tools by This is an excellent format for students to explore which to assess the effectiveness of curricular inno- their own feelings about sexual issues and to learn vations in the real world has been a long-standing from others with different perspectives [33]. Edu- problem in education research [9]. It is important to cational opportunities that involve a greater measure the effectiveness of sexual health curricula degree of interactivity are generally well received in preparing medical students to evaluate and treat [39,58]. These groups should ideally involve sexual problems in patients. How this is to be students from different backgrounds under the

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guidance of a trained and experienced facilitator with barrier contraceptives presenting for annual who can elicit participation from all involved and physical (sexuality/safer sex education for the keep the tone respectful and interested. Such elderly, acknowledgement that sexual activity interventions have been shown to improve stu- occurs in the geriatric population, possible sexual dent’s ability to examine their own beliefs and gain dysfunction); (iii) counseling and treatment for a respect for the perspectives of others, even those heterosexual 24-year-old heroin user who was with whom they may not agree about controversial raped by another man and subsequently found to topics such as homosexuality and contraception be HIV and hepatitis C positive (issues of rape, [49,53,64]. Discussion groups may also be an HIV status and partner disclosure, drug use and opportunity to learn about the opinions and sexuality); and (iv) a married 56-year-old man or thoughts of individuals of different gender. Elicit- woman involved in an extramarital affair (without ing a sexual history from a patient of a different spousal knowledge or consent) who has herpes that gender is an acknowledged challenge in medical he or she has not disclosed to his or her spouse practice; discussing ways to facilitate these (issues of potential morality discordance between exchanges is essential [17,24]. patient and provider, need for disclosure to at-risk Small Group Case-Based Seminars person vs. respect for patient confidentiality). Each case presentation was followed by discussion and These permit more in-depth exploration of subtle debriefing by the small group [49]. nuances that affect how certain problems should While useful, role play sessions may be difficult be evaluated and managed in individual patients to facilitate as participants often have trouble [62]. This has been used to good effect in many staying “in character” with friends/colleagues. Pro- recent student-led curriculum innovations [46,49]. vision of feedback from this type of learning is also Whereas discussion groups pertain more to self- problematic. Logistical limitations make it imprac- reflection and awareness, this intervention is tar- tical for one-on-one role play to be observed by a geted toward building knowledge on how to relate single trained facilitator; an alternative may be role to patients. Case-based scenarios do not replicate play within the context of a small group session with real-world interpersonal dynamics and thus may feedback provided by the group. This is more time/ not fully prepare students for interactions with live resource efficient but some individuals may get a patients. sense of “stage fright,” which may tend to diminish Role Play their efficacy at role-play interactions. Scripted role play (assigning identities to two individuals who then act out a scenario) can be useful, Standardized Patient (SP) Scenarios particularly to practice using open-ended ques- Similar to role play, this involves students interact- tions and normalizing statements to improve ing with a trained SP who acts out a certain role. patient comfort. Role play may be utilized by expe- While utilization of an SP may add substantial rienced trainers as a means to demonstrate sexual- logistical and financial expense, it mitigates the history-taking skills for a small or large group limitations of role play in that the trainee does not audience; participants may also participate in role know the SP and it is hence easier to stay “in play so as to personally practice interviewing skills character.” Individualized feedback on perfor- [38,49]. Scripted role-play teaching for sexuality mance may be given immediately by the SP and/or issues received approval ratings of around 90% in by a faculty observer; this may serve as a more a study from the Chicago Medical School com- meaningful measure of student skills compared pared with an average approval rating of 68% for with self-assessment. In certain circumstances it other courses in an introduction to clinical medi- may also be useful to videotape the interaction and cine curriculum [49]. Particular scripts for role obtain specific feedback from an instructor. This play in this curriculum included increasingly sort of intervention may be useful as a formative complex scenarios involving: (i) contraception introduction to prepare students on how to inter- counseling for a sexually active 16-year-old female act with patients of various types or as a summative patient with a 19-year-old male partner (issues of “final examination” that may be used to assess adolescent sexuality, contraception, and laws per- student achievement [8,65]. taining to statutory rape); (ii) evaluation of a SPs are not a new nor novel educational tool 71-year-old widowed female patient unfamiliar [66] but have been featured prominently in many

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recent reports. The enhanced curriculum in sexu- scenarios and provide appropriate feedback to ality at Case Western Medical School is an medical student learners. In some situations, par- example. In this curriculum, students rotate ticularly in large urban areas, training and con- through a multi-station examination in which they tracting of educators can be accomplished by perform tasks such as interviews, physical exams, organizations external to the medical school; this and counseling with SPs in realistic settings during may permit recruitment of a more diverse and which their interaction is recorded by video representative cohort of potential SP. An example camera. At each station learner performance is of such an organization is Project Prepare in the evaluated with specific checklists or global rating San Francisco Bay Area. Project Prepare provides scales, completed by faculty proctors and/or SPs highly trained educators to area medical schools [37]. At Tufts University School of Medicine, SP including the University of California at San Fran- encounters are a part of the third-year clerkship cisco, Stanford University, and Tuoro University curriculum and include the opportunity to interact College of Osteopathic Medicine. with SP portraying a young woman seeking contraception, a homosexual man at risk for HIV, and Community/Peer Education a man noncompliant with blood pressure medica- In addition to providing a valuable community tions secondary to medication-induced sexual dys- service, educational outreach to the community function [38]. Another report from the University (particularly adolescents, the elderly, LGBT of Kentucky provided follow-up data on students people, etc.) may help students to examine their who enrolled in a 4-hour SP workshop intended to own beliefs about sexuality and to gain valuable teach sexual health interview skills in four SP clini- perspectives from the individuals with whom they cal scenarios: a 17-year-old female SP presenting interact. Many medical schools offer such pro- for a health physical, a 27-year-old man requesting grams on topics that may pertain to human sexu- an HIV test, a 34-year-old woman requesting oral ality [24]. While this sort of involvement should contraceptives, and a 61-year-old woman present- not be a specific requirement, it may be useful as a ing for a checkup [52]. The SP encounters were means to fulfill a public service requirement for followed by a discussion and teaching with a those schools that require some form of commu- faculty preceptor. Follow-up testing at 3.5 weeks nity outreach. Senior students may also consider during an encounter with an SP portraying a serving as teaching assistances for junior medical 28-year-old woman concerned about having an students. A small group session for first-year stu- STI indicated that students who had participated dents facilitated by a faculty member and a fourth- in the workshop scored a full standard deviation year student was substantially useful in reducing better on a checklist of required inquiries pertain- apprehension around dissection of the pelvis ing to HIV counseling and sexual history taking during the gross anatomy course [19]. and had significantly better “interpersonal interviewing skills” relative to peers who had not par- Immersion/Desensitization ticipated [52]. A follow-up study from the same This technique involves exposing students to a group confirmed these findings and furthermore variety of sexual practices, typically in a video indicated that participants had better scores on format, with the intention of desensitizing them to written exam materials pertaining to sexual health sexual acts with which they may not have personal and history taking [55]. These studies are of par- experience or knowledge. This technique was ticular note in that subjects did not specifically utilized in the 1970s. Examples include video select this workshop; rather, they were enrolled in depiction of “male-female genital intercourse, it depending on what time of year they completed homosexuality, cunnilingus, fellatio, orgies, besti- their ambulatory internal medicine rotations [52]. ality, and sadomasochism.” [67] While ostensibly While not a truly randomized cohort, this study well intentioned, it must be considered that display does suggest that this intervention may have ben- of sexually explicit imagery may be offensive to eficial effects for students irrespective of their some students and without proper context such baseline comfort and facility in sexual health imagery may even enhance prejudicial feelings or inquiry. discomfort about certain sexual acts and/or iden- It is critical that SPs be highly trained and moti- tities. Indeed, a 1976 study indicated that record- vated individuals who can accurately portray case ing and review of practice patient interview

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sessions were more useful than desensitization siastic about their topic and well prepared for [66]. Desensitization may have a role in sexuality student interactions [39]. In turn, faculty should be education, but in our opinion it should be a limited informed about the size and level of their expected one and only used only when context for various audience as well as the educational expectations of sexual acts can be provided by experienced educa- the activity so as to best tailor their educational tors [32]. outreach [39,49]. Faculty involvement in the process is essential not just for direction of student Training in Interviewing Couples learning but also to ensure that university Involving the partner in discussion of sexual prob- resources and sanction continue to be directed lems is acknowledged as a particular challenge toward sexuality education. Given the limited among care providers [37]. While training in quantity of time and resources available in medical couples-based techniques might be of great benefit school, a strong voice of advocacy from trusted and [6], this is an advanced technique that would respected faculty is required to ensure that these require the participation of two SPs and ideally a topics continue to be represented. This requires trained facilitator/observer. Given that few provid- support from departmental and university bodies ers will provide services to both partners of a to ensure that faculty are given time to develop couple this technique is probably best reserved for curricula and keep themselves up to date by review upper-level students/trainees with a particular of literature and attendance at educational meet- interest in sexual health; students who are not ings. Unfortunately, this need may not be receiv- interested in specializing in sexual health may not ing adequate attention at the current time. A 2003 find this type of training time effective. survey reported that just 45 of 101 respondent Testing/Course Credit medical schools (44.6%) offer graduate medical It is a near universal fact that students at all levels education courses in human sexual function and of training are more motivated to learn material on dysfunction [36]. which they will subsequently be tested or for Beyond simple faculty support, consideration which they will receive some form of curriculum may be given to providing healthcare professionals credit [37,39]. Some means of assessment and with extensive experience and training in address- meaningful feedback from sexuality curricula must ing sexual issues with special certification. The be incorporated. This can take the form of written European Academy of Sexual Medicine has made material on standard tests, feedback/grading from progress toward providing formal certification in SP encounters, and credit for active participation sexual medicine under the auspices of the Union of in small group discussions. While direct assess- European Medical Specialists [65]. The Interna- ment of clinical skills (using observed clinical tional Society for the Study of Women’s Sexual encounters and/or SP) has become standard for Health has recently established a Fellowship Cer- accreditation by both the LCME and the Ameri- tification program [68]. The creation of these cer- can College of Graduate Medical Education, these tification programs requires development of a standards have not been universally applied to formal core curriculum and fund of knowledge/ skills in sexuality education for medical students. skills that any specialist with interest in sexual Clearly, there is a need for more rigorous stan- medicine will be expected to possess. Depending dards. Testing may also provide a valuable role in on the given specialists training and interests, objective validation of existing curricula; many optional modules may be useful to more fully published reports on new curricula have relied on develop areas of particular expertise (such as sur- self-reported comfort or competence in addressing gical vs. medical vs. psychological approaches to sexuality issues, end points that are of questionable sexual problems) [65]. While the requirements for objective merit. such certifications go well beyond what is expected of undergraduate medical students, development Faculty Development of these specialty qualifications may serve as a The recruitment, retention, and continued devel- valuable blueprint for future curriculum develop- opment of a core faculty in sexual health are criti- ments in medical students. Individuals who had cal to the success of any sexual health education completed such a curriculum would be ideal key innovation [37]. Student generally learn more and faculty for medical student educational programs respond more favorably when lecturers are enthu- on sexuality.

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Development of a Unified Curriculum for (c) Analysis and Interpretation of Data Institution at All Medical Schools Alan Shindel; Sharon Parish While there is variability in the cultural values, learning philosophy, and resources in medical Category 2 schools throughout the world, sexuality is a uni- (a) Drafting the Article versal human concern. Development of a compre- Alan Shindel hensive curriculum on sexuality may help facilitate (b) Revising It for Intellectual Content education at medical schools worldwide. Ideally Sharon Parish this curriculum would be respectful of local customs and beliefs while simultaneously ensuring Category 3 that all physicians are trained to handle sexual con- (a) Final Approval of the Completed Article cerns and questions in a manner befitting an occu- Alan Shindel; Sharon Parish pation dedicated to the well-being and health of all people. References 1 Pan American Health Organization WHO, World Association Conclusions for Sexology. Promotion of Sexual Health: Recommendations Despite substantial variability in the quantity and for Action. 2000: 1–58. 2 Lindau ST, Schumm LP, Laumann EO, Levinson W, quality of sexuality education in medical school, a O’Muircheartaigh CA, Waite LJ. A study of sexuality and number of encouraging developments over the health among older adults in the United States. N Engl J Med past decade have highlighted methods and means 2007;357:762–74. by which tomorrow’s physicians can be better pre- 3 Sadovsky R, Nusbaum M. Sexual health inquiry and support is a primary care priority. J Sex Med 2006;3:3–11. pared to address the needs of their future patients. 4 Resnik M. What is sexual medicine? Int J Impot Res In many cases innovation has been pioneered by 2005;17:464. medical students themselves, particularly those 5 NIH Panel on Impotence. NIH consensus conference. Impo- tence. JAMA 1993;270:83–90. who have premedical school experience in repro- 6 Lief H, Berman EM, eds. Sexual interviewing through the ductive health issues [39,49]. It behooves practic- patient’s life cycle. Chicago, IL, USA: American Medical Asso- ing physicians, other healthcare providers, and ciation; 1981. medical school curriculum directors to provide 7 Parish SJ, Clayton AH. Sexual medicine education: Review and commentary. J Sex Med 2007;4:259–67; quiz 68. both financial and logistical support in addition to 8 Wittenberg A, Gerber J. Recommendations for improving mentorship for medical students who have a desire sexual health curricula in medical schools: Results from a two- to enhance sexuality education. Sexual medicine arm study collecting data from patients and medical students. J professionals have a duty to take an active role Sex Med 2009;6:362–8. 9 Parish SJ, Rubio-Aurioles E. Education in sexual medicine: in the development of new curricula in sexuality Proceedings from the international consultation in sexual education. medicine, 2009. J Sex Med 2010;7:3305–14. 10 McCance KL, Moser R Jr, Smith KR. A survey of physicians’ Corresponding Author: Alan Shindel, MD, Depart- knowledge and application of AIDS prevention capabilities. ment of Urology, University of California, Davis, 4860 Am J Prev Med 1991;7:141–5. Y Street, Suite 3500, Sacramento, CA 95816, USA. Tel: 11 Sobecki JN, Curlin FA, Rasinski KA, Lindau ST. What we don’t talk about when we don’t talk about sex: Results of a (916) 734-5154; Fax: (916) 734-8094; Email: national survey of US obstetrician/gynecologists. J Sex Med [email protected] 2012;9:1285–94. Conflict of Interest: Dr. Shindel has served on the speak- 12 Rosen R, Kountz D, Post-Zwicker T, Leiblum S, Wiegel M. Sexual communication skills in residency training: The Robert er’s bureau for Endo. He has served as a consultant for Wood Johnson model. J Sex Med 2006;3:37–46. Group H, AMS, Cerner. 13 Merrill JM, Laux LF, Thornby JI. Why doctors have difficulty with sex histories. South Med J 1990;83:613–7. 14 McGarvey E, Peterson C, Pinkerton R, Keller A, Clayton A. Statement of Authorship Medical students’ perceptions of sexual health issues prior to a curriculum enhancement. Int J Impot Res 2003;15(suppl 5): Category 1 S58–66. 15 Shindel AW, Ando KA, Nelson CJ, Breyer BN, Lue TF, Smith (a) Conception and Design JF. Medical student sexuality: How sexual experience and sexu- Alan Shindel; Sharon Parish ality training impact U.S. and Canadian medical students’ (b) Acquisition of Data comfort in dealing with patients’ sexuality in clinical practice. Alan Shindel; Sharon Parish Acad Med 2010;85:1321–30.

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16 Steinauer J, LaRochelle F, Rowh M, Backus L, Sandahl Y, 34 Lief HI, Ebert RK. A survey of sex education in medical Foster A. First impressions: What are preclinical medical stu- schools. New York: Spectrum Publications; 1976. dents in the US and Canada learning about sexual and repro- 35 Lloyd JA, Steinberger E. Survey and analysis of educational ductive health? Contraception 2009;80:74–80. efforts in reproductive biology and human sexuality in Ameri- 17 Burd ID, Nevadunsky N, Bachmann G. Impact of physician can medical schools. J Reprod Med 1980;24:17–21. gender on sexual history taking in a multispecialty practice. J 36 Solursh DS, Ernst JL, Lewis RW, Prisant LM, Mills TM, Sex Med 2006;3:194–200. Solursh LP, Jarvis RG, Salazar WH. The human sexuality 18 Athanasiadis L, Papaharitou S, Salpiggidis G, Tsimtsiou education of physicians in North American medical schools. Z, Nakopoulou E, Kirana PS, Moisidis K, Hatzichristou D. Int J Impot Res 2003;15(suppl 5):S41–5. Educating physicians to treat erectile dysfunction patients: 37 Kingsberg SA, Malemud CJ, Novak T, Cole-Kelly K, Wile Development and evaluation of a course on communica- MZ, Spanos P, Nosek TM. A comprehensive approach to tion and management strategies. J Sex Med 2006;3:47–55. enhancing sexual health education in the Case Western 19 Ferrara E, Pugnaire MP, Jonassen JA, O’Dell K, Clay M, Reserve University School of Medicine. Int J Impot Res Hatern D, Carlin M. Sexual health innovations in undergradu- 2003;15(suppl 5):S51–7. ate medical education. Int J Impot Res 2003;15(suppl 5):S46– 38 Sack S, Drabant B, Perrin E. Communicating about sexuality: 50. An initiative across the core clerkships. Acad Med 2002; 20 Ng CJ, McCarthy SA. Teaching medical students how to take 77:1159–60. a sexual history and discuss sexual health issues. Med J Malay- 39 Caro-Bruce E, Schoenfeld E, Nothnagle M, Taylor J. Address- sia 2002;57(suppl E):44–51. ing gaps in abortion education: A sexual health elective created 21 Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, Kyrana E, by medical students. Med Teach 2006;28:244–7. Salpigidis G, Hatzichristou D. Predictors of physicians’ 40 Council on Scientific Affairs, American Medical Association. involvement in addressing sexual health issues. J Sex Med Health care needs of gay men and lesbians in the United States. 2006;3:583–8. JAMA 1996;275:1354–9. 22 Bullard DG, Caplan H. Sexual problems. In: Feldman MD, 41 American Medical Association. Policy 160-991: Health care Christensen JF, eds. Behavioral medicine in primary care: A needs of gay men and lesbians in the U.S. AMA Policy Com- practical guide. 2nd edition. Lange Medical Books/Mcgraw- pendium. Chicago: American Medical Association; 1995:148– Hill: Stamford, CT; 2002:274–92. 9. 23 Shindel AW, Moser CA. Why are the paraphilias mental dis- 42 Committee on Lesbian, Gay, Bisexual, and Transgender orders? J Sex Med 2011;8:927–9. Health Issues and Research Gaps and Opportunities; Board on 24 Faulder GS, Riley SC, Stone N, Glasier A. Teaching sex edu- the Health of Select Populations; Institute of Medicine. The cation improves medical students’ confidence in dealing with health of lesbian, gay, bisexual, and transgender people: Build- sexual health issues. Contraception 2004;70:135–9. ing a foundation for better understanding. 2011. 25 Labby D. Disturbances in the physician-patient relationship: 43 Wallick MM, Cambre KM, Townsend MH. How the topic of Effects on sexual functioning. In: Lief HI, ed. Sexual problems homosexuality is taught at U.S. medical schools. Acad Med in medical practice. American Medical Association: Chicago, 1992;67:601–3. IL; 1981:113–8. 44 Obedin-Maliver J, Goldsmith ES, Stewart L, Shite W, Tran E, 26 Sandler B. The student and sex education. Lancet 1957; Brenman S, Wells M, Fetterman DM, Garcia G, Lunn MR. 272:832–3. Lesbian, gay, bisexual, and transgender-related content in 27 Hartmann U, Burkart M. Erectile dysfunctions in patient- undergraduate medical education. JAMA 2011;306:971–7. physician communication: Optimized strategies for addressing 45 Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. sexual issues and the benefit of using a patient questionnaire. J Medical students’ ability to care for lesbian, gay, bisexual, and Sex Med 2007;4:38–46. transgendered patients. Fam Med 2006;38:21–7. 28 Politi MC, Clark MA, Armstrong G, McGarry KA, Sciamanna 46 Kelley L, Chou CL, Dibble SL, Robertson PA. A critical CN. Patient-provider communication about sexual health intervention in lesbian, gay, bisexual, and transgender health: among unmarried middle-aged and older women. J Gen Intern Knowledge and attitude outcomes among second-year medical Med 2009;24:511–6. students. Teach Learn Med 2008;20:248–53. 29 Sadovsky R, Alam W, Enecilla M, Cosiquien R, Tipu O, 47 Malhotra S, Khurshid A, Hendricks KA, Mann JR. Medical Etheridge-Otey J. Sexual problems among a specific popula- school sexual health curriculum and training in the United tion of minority women aged 40–80 years attending a primary States. J Natl Med Assoc 2008;100:1097–106. care practice. J Sex Med 2006;3:795–803. 48 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the 30 Nusbaum MR, Helton MR, Ray N. The changing nature of United States: Prevalence and predictors. JAMA 1999;281: women’s sexual health concerns through the midlife years. 537–44. Maturitas 2004;49:283–91. 49 Leeper H, Chang E, Cotter G, MacIntosh P, Scott F, Apan- 31 Laumann EO, Glasser DB, Neves RC, Moreira ED Jr. A taku L, Broutman L, Lazaraus C. A student-designed and population-based survey of sexual activity, sexual problems student-led sexual-history-taking module for second-year and associated help-seeking behavior patterns in mature adults medical students. Teach Learn Med 2007;19:293–301. in the United States of America. Int J Impot Res 2009;21: 50 Calderone M, ed. Sex education and education for sexuality: 171–8. The physician’s role. Hagerstown, MD: Harper and Row Pub- 32 Lief H, ed. Sexual education of the medical student: Implica- lishers; 1974. tions for family planning. Baltimore, MD: Willam & Wilkins 51 Nicolosi A, Laumann EO, Glasser DB, Moreira ED Jr, Paik A, Co; 1970. Gingell C. Sexual behavior and sexual dysfunctions after age 33 Eliot J, Houser CA. Medical education: Survey of status. 40: The global study of sexual attitudes and behaviors. Urology In: Calderone MS, ed. Manual of family planning and contra- 2004;64:991–7. ceptive practice. Baltimore, MD: Williams Willkins Co; 52 Haist SA, Griffith IC, Hoellein AR, Talente G, Montgomery 1970:155–62. T, Wilson JF. Improving students’ sexual history inquiry and

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HIV counseling with an interactive workshop using standard- Freemantle N, Davis DA, Haynes RB, Harvey EL. Educa- ized patients. J Gen Intern Med 2004;19:549–53. tional outreach visits: Effects on professional practice and 53 McKelvey RS, Webb JA, Baldassar LV, Robinson SM, Riley G. health care outcomes. Cochrane Database Syst Rev Sex knowledge and sexual attitudes among medical and nursing 2007;(4):CD000409. students. Aust N Z J Psychiatry 1999;33:260–6. 61 Forsetlund L, Bjorndal A, Rashidian A, Jamvedt G, O’Brien 54 Lief H, ed. Sexual knowledge, attitudes, and behavior of MA, Wolf D, Davis D, Odgaard-Jensen J, Oxman AD. Con- medical students: Implications for medical practice. Hager- tinuing education meetings and workshops: Effects on profes- stown, MD, USA: Harper and Row; 1974. sional practice and health care outcomes. Cochrane Database 55 Haist SA, Lineberry MJ, Grifﬁth CH, Hoellein AR, Syst Rev 2009;(2):CD003030. Talente GM, Wilson JF. Sexual history inquiry and HIV 62 Haslegrave M, Olatunbosun O. Incorporating sexual and counseling: Improving clinical skills and medical knowledge reproductive health care in the medical curriculum in devel- through an interactive workshop utilizing standardized oping countries. Reprod Health Matters 2003;11:49–58. patients. Adv Health Sci Educ Theory Pract 2008;13:427– 63 Wagner G. Sexual medicine in the medical curriculum. Int J 34. Androl 2005;28(suppl 2):7–8. 56 Espey E, Ogburn T, Chavez A, Qualls C, Leyba M. Abortion 64 Dixon-Woods M, Regan J, Robertson N, Young B, Cordle C, education in medical schools: A national survey. Am J Obstet Tobin M. Teaching and learning about human sexuality in Gynecol 2005;192:640–3. undergraduate medical education. Med Educ 2002;36:432– 57 Espey E, Ogburn T, Leeman L, Nguyen T, Gill G. Abortion 40. education in the medical curriculum: A survey of student atti- 65 Eardley I. A curriculum for sexual medicine? J Sex Med tudes. Contraception 2008;77:205–8. 2009;6:1195–8. 58 Davis D, O’Brien MA, Freemantle N, Wolf FM, Mazmanian 66 Engel IM, Resnick PJ, Levine SB. The use of programmed P, Taylor-Vaisey A. Impact of formal continuing medical edu- patients and videotape in teaching medical students to take a cation: Do conferences, workshops, rounds, and other tradi- sexual history. J Med Educ 1976;51:425–27. tional continuing education activities change physician 67 Hammond C, Hawkins DR. Teachingsexual, marital, and con- behavior or health care outcomes? JAMA 1999;282:867–74. traceptive counseling. In: Abse DW, Nash EM, Louden LMR, 59 Jamtvedt G, Young JM, Kristoffersen DT, O’Brien MA, eds. Marital and sexual counseling in medical practice. Hager- Oxman AD. Does telling people what they have been doing stown, MD: Harper and Row; 1974:462–73. change what they do? A systematic review of the effects of audit 68 ISSWSH Felloswhip Committee. ISSWSH Fellowship. and feedback. Qual Saf Health Care 2006;15:433–6. 2012. Available at: http://www.isswsh.org/pdf/ISSWSH_ 60 O’Brien MA, Rogers S, Jamtvedt G, Oxman AD, Odgaard- Fellowship_Document_%204_15_2011.pdf (accessed June 28, Jensen J, Kristoffersen DT, Forsetlund L, Bainbridge D, 2012).

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CME Multiple Choice Questionsjsm_2987 18

1. The Liaison Committee on Medical Education c) Patients with non-normative sexual speciﬁcally recommends that medical school cur- practices ricula include coverage of all but which of the d) Patients with a history of sexual abuse following topics? e) All of the above a) Gender biases b) Communication skills 4. Which of the following educational formats has c) Diverse cultures and belief systems been shown to be best-suited for examination d) Contraception of personal beliefs and acquisition of respect for e) Medical consequences of societal problems alternative beliefs? a) Lectures 2. According to the most recent data on this topic, b) Case Based Scenarios issues in lesbian, gay, bisexual, and transgender c) Discussion groups (LGBT) health are currently covered during d) Immersion pre-clinical years at approximately what percent- e) Standardized patient encounters age of North American medical schools? a) 90% 5. Which of the following sexuality education b) 75% topics is least relevant for providers who care c) 50% for children and adolescents? d) 25% a) Sexuality decision making tools e) 10% b) Sexual Dysfunction c) Contraception 3. Evidence suggests that students/providers may d) Sexual Development and puberty have discomfort or difﬁculty when taking sexual e) Boundaries histories from which of the following groups of patients? a) Patients at the extremes of age b) Patients of a different gender

To complete this activity and earn credit, please go to www.wileyhealthlearning.com/issm

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